12 Month Questionnaire
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- Tabitha Chapman
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1 11 months 0 days to 12 months 30 days (inclusive) 12 Month Questionnaire Baby s name: Baby s date of birth: Boy Girl If baby was born 3 or more weeks prematurely, please indicate the number of weeks premature: Date ASQ-3 completed by parent/caregiver: Date of review with health professional: Baby s home address: Town: Postcode: Person completing the questionnaire: Relationship to baby: Home tel: Mobile no: address: All babies develop at different rates and in different ways. Please do not worry if your baby is not doing all or any of the activities mentioned in the questionnaire. It is not a test. The activities are simply one way of understanding how your baby is progressing. Possible answers: Yes = your baby does this activity (or has done it and has now progressed, e.g., crawling, but is now walking) Sometimes = your baby is just beginning to do this activity (but does not do it regularly) Not Yet = your baby has not yet started doing this Please leave blank any activities your baby has not been able to try with you.
2 12 11 months 0 days Month Questionnaire to 12 months 30 days (inclusive) On the following pages are questions about activities babies may do. Your baby may have already done some of the activities described here, and there may be some your baby has not begun doing yet. For each item, please fill in the circle that indicates whether your baby is doing the activity regularly (yes), sometimes, or not yet. Important Points to Remember: Try each activity with your baby before marking a response. Make completing this questionnaire a game that is fun for you and your baby. Make sure your baby is not tired or hungry. Please bring this questionnaire with you to your baby s health and development review. Notes: COMMUNICATION 1. Does your baby make two similar sounds like ba-ba, da-da, or gaga? (The sounds do not need to mean anything.) 2. If you ask your baby to, does he play at least one nursery game even if you don t show him the activity yourself (such as bye-bye Peeka-boo, clap your hands, Pat-a-cake )? 3. Without showing her what you mean, does your baby follow one simple command, such as Come here, Give it to me, or Put it back? 4. Does your baby say three words, such as Mama, Dada, and Baba? (A word is a sound or sounds your baby says consistently to mean someone or something.) 5. When you ask, Where is the ball (hat, shoe, etc.)? does your baby look at the object? (Make sure the object is present. Mark yes if she knows one object.) 6. When your baby wants something, does he tell you by pointing to it? YES SOMETIMES T YET COMMUNICATION TOTAL GROSS MOTOR 1. While holding onto furniture, does your baby bend down and pick up a toy from the floor and then return to a standing position? YES SOMETIMES T YET 2. While holding onto furniture, does your baby lower himself with control (without falling or flopping down)? 3. Does your baby walk beside furniture while holding on with only one hand? page 2 of 6
3 Mmmmmmmmmmmmmmmm12 Month Questionnaire page 3 of 6 GROSS MOTOR (continued) 4. If you hold both hands just to balance your baby, does he take several steps without tripping or falling? (If your baby already walks alone, mark yes for this item.) YES SOMETIMES T YET 5. When you hold one hand just to balance your baby, does she take several steps forward? (If your baby already walks alone, mark yes for this item.) 6. Does your baby stand up in the middle of the floor by himself and take several steps forward? GROSS MOTOR TOTAL FINE MOTOR YES SOMETIMES T YET 1. After one or two tries, does your baby pick up a piece of string with his first finger and thumb? (The string may be attached to a toy.) 2. Does your baby pick up a small cube of bread with the tips of her thumb and a finger? She may rest her arm or hand on the table while doing it. 3. Does your baby put a small toy down, without dropping it, and then take his hand off the toy? 4. Without resting her arm or hand on the table, does your baby pick up a small cube of bread with the tips of her thumb and a finger? * 5. Does your baby throw a small ball with a forward arm motion? (If he simply drops the ball, mark not yet for this item.) 6. Does your baby help turn the pages of a book? (You may lift a page for him to grasp.) FINE MOTOR TOTAL * If Fine Motor Item 4 is marked yes or sometimes, mark Fine Motor Item 2 yes.
4 PROBLEM SOLVING Mmmmmmmmmmmmmmmm12 Month Questionnaire YES SOMETIMES T YET page 4 of 6 1. While holding a small toy in each hand, does your baby clap the toys together (like Pat-a-cake )? 2. Does your baby poke at or try to get a small cube of bread that is inside a small, clear plastic bottle (such as a small water bottle or baby bottle)? 3. After watching you hide a small toy under a piece of paper or cloth, does your baby find it? (Be sure the toy is completely hidden.) 4. If you put a small toy into a bowl or box, does your baby copy you by putting in a toy, although she may not let go of it? (If she already lets go of the toy into a bowl or box, mark yes for this item.) 5. Does your baby drop two small toys, one after the other, into a container like a bowl or box? (You may show him how to do it.) * 6. After you scribble back and forth on paper with a crayon (or a pencil or pen), does your baby copy you by scribbling? (If she already scribbles on her own, mark yes for this item. ) PERSONAL-SOCIAL 1. When you hold out your hand and ask for his toy, does your baby offer it to you even if he doesn t let go of it? (If he already lets go of the toy into your hand, mark yes for this item.) 2. When you dress your baby, does she push her arm through a sleeve once her arm is started in the hole of the sleeve? 3. When you hold out your hand and ask for his toy, does your baby let go of it into your hand? 4. When you dress your baby, does she lift her foot for her shoe, sock, or trouser leg? 5. Does your baby roll or throw a ball back to you so that you can return it to him? PROBLEM SOLVING TOTAL * If Problem Solving Item 5 is marked yes or sometimes, mark Problem Solving Item 4 yes. YES SOMETIMES T YET 6. Does your baby play with a doll or soft toy by hugging it? PERSONAL-SOCIAL TOTAL
5 OVERALL Mmmmmmmmmmmmmmmm12 Month Questionnaire page 5 of 6 Parents and providers may use the space below for additional comments. 1. Does your baby use both hands and both legs equally well? If no, explain: 2. Does your baby play with sounds or seem to make words? If no, explain: YES 3. When your baby is standing, are her feet flat on the surface most of the time? If no, explain: 4. Do you have concerns that your baby is too quiet or does not make sounds like other babies? If yes, explain: 5. Does either parent have a family history of childhood deafness or hearing problems? If yes, explain:
6 OVERALL (continued) Mmmmmmmmmmmmmmmm12 Month Questionnaire 6. Do you have concerns about your baby s eyesight? If yes, explain: YES page 6 of 6 7. Has your baby had any medical or health-related problems in the last few months? If yes, explain: YES 8. Do you have any concerns about your baby s behaviour? If yes, explain: 9. Does anything about your baby worry you? If yes, explain:
Copyright 1999 by Paul H. Brookes Publishing Co.
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